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Clinical guidelines

Guidelines for preventive activities in general practice 9th edition

4. Preventive activities in middle age

Age 0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-79 > 80

The recommended specific activities for low-risk patients in the 45–64 years age group are listed in Table 4.1. Patients should be offered these opportunistically, or at two-year to five-year intervals.

Planned health checks in general practice of middle-aged adults have been demonstrated to improve the frequency of the management of smoking, nutrition, alcohol and physical activity (SNAP) behavioural risk factors; screening for cervical and colorectal cancer (CRC); and hyperlipidaemia.1–3

There is also evidence that Aboriginal and Torres Strait Islander health checks improve early detection of diabetes and provision of preventive care.4 However, there is mixed evidence for the effectiveness of interventions to address multiple risk factors.5 These checks may be facilitated by the involvement of practice nurses.6–8 Interventions should be tailored to the level of risk, and the use of the 5As framework (Ask, Assess, Advise and agree, Assist, Arrange follow-up) is recommended as a guide to their delivery in primary healthcare.9

Health inequity

What are the key equity issues and who is at risk?

  • Midlife, between 45 and 64 years of age, is particularly a time of determining patient risk factors and offering screening for health conditions. Multimorbidity, particularly physical–mental health comorbidity, is an important issue in middle aged populations. Social disadvantage can hasten the onset of multimorbidity by about 10–15 years, suggesting screening should start earlier in high-risk populations, including Aboriginal and Torres Strait Islander peoples (eg at 30 years of age). This may be a critical time for preventive interventions to reduce later life chronic illness.10
  • The impact of income-related inequalities on the prevalence of common mental health disorders and psychological distress is particularly seen in middle aged people.11

What can GPs do?

  • Refer to the general principles of providing patient education and supporting health literacy in disadvantaged groups.
  • Be aware that disadvantaged groups may be less likely to access health checks,12 so proactive efforts to go outside the practice (eg to workplaces) may be needed or preventive care may be built in opportunistically to routine consultations.
  • Actively manage vulnerable patients by recalling patients by phone or text messages for preventive care.
Table 4.1. Age-related health checks for low-risk patients in middle age
AgeWhat should be done
45–49 years Ask about:
Measure
Perform
  • Papanicolaou (Pap) test every two years (until April 2017) - Refer to Section 9.5
  • Human papillomavirus (HPV) test every five years (from May 2017)
  • mammogram for women dependent on her individual degree of risk - Refer to Section 9.3
  • 23–valent pneumococcal polysaccharide vaccine (23vPPV) and influenza vaccination for all Aboriginal and Torres Strait Islander peoples - Refer to Chapter 6
  • Influenza and diphtheria, tetanus, and acellular pertussis (dTpa adolescent/adult version) vaccination for pregnant women - Refer to Chapter 6
  • genetic testing as part of preconception planning

Calculate
50–64 years Ask about:
Measure
Perform
  • Colorectal cancer (CRC) screening with faecal occult blood testing (FOBT) at least every two years - Refer to Section 9.2
  • Pap test every two years (until April 2017) - Refer to Section 9.5
  • HPV test every five years (from May 2017)
  • mammography for women dependent on individual degree of risk - Refer to Section 9.3
  • 23vPPV and influenza vaccination for all Aboriginal and Torres Strait Islander peoples - Refer to Chapter 6
  • vaccination for diphtheria, tetanus (DT); dTpa should be used in place of DT when providing booster tetanus immunisations - Refer to Chapter 6

Calculate
23vPPV, 23-valent pneumococcal polysaccharide vaccine; AUSDRISK, Australian type 2 diabetes risk assessment tool; BMI, body mass index; BP, blood pressure; DT, diphtheria, tetanus; dTpa, diphtheria, tetanus, and acellular pertussis(adolescent/adult version); HPV, human papillomavirus; Pap, Papanicolaou; SNAP, smoking, nutrition, alcohol and physical activity
Table 4.2. Preventive interventions in middle age
InterventionTechnique
Health education Tailor health advice or education to the patient’s risk, stage of change and health literacy (Chapter II. Patient education and health literacy)
Practice organisation Use clinical audit to identify patients who have not had preventive activity. Recall to practice or opportunistically arrange a 45–49 years health assessment

References

  1. Boulware LE, Marinopolous S, Phillips KA, et al. Systematic review: The value of the periodic health evaluation. Ann Intern Med 2007;146(4):289–300.
  2. Dowell AC, Ochera JJ, Hilton SR, et al. Prevention in practice: Results of a 2-year follow-up of routine health promotion interventions in general practice. Fam Pract 1996 Aug;13(4):357–62.
  3. Imperial Cancer Research Fund OXCHECK Study Group. Effectiveness of health checks conducted by nurses in primary care: Final results of the OXCHECK study. BMJ 1995;310(6987):1099–104.
  4. Spurling GK, Hayman NE, Cooney AL. Adult health checks for Indigenous Australians: The first year’s experience from the Inala Indigenous Health Service. Med J Aust 2009;190(10):562–64.
  5. Eriksson MK, Franks PW, Eliasson M. A 3-year randomized trial of lifestyle intervention for cardiovascular risk reduction in the primary care setting: The Swedish Bjorknas study. PLOS ONE 2009;4(4):e5195.
  6. Raftery JP, Yao GL, Murchie P, Campbell NC, Ritchie LD. Cost effectiveness of nurse led secondary prevention clinics for coronary heart disease in primary care: Follow up of a randomised controlled trial. BMJ 2005;330(7493):707.
  7. Family Heart Study Group. Randomised controlled trial evaluating cardiovascular screening and intervention in general practice: Principal results of British family heart study. BMJ 1994;308(6924):313–20.
  8. Engberg M, Christensen B, Karlsmose B, Lous J, Lauritzen T. General health screenings to improve cardiovascular risk profiles: A randomized controlled trial in general practice with 5-year follow-up. J Fam Pract 2002;51(6):546–52.
  9. World Health Organization. Screening for various cancers. Geneva: WHO, 2008. Available at www.who.int/cancer/detection/variouscancer/en/ [Accessed 3 May 2016].
  10. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: A cross-sectional study. Lancet 2012;380(9836):37–43.
  11. Lang IA, Llewellyn DJ, Hubbard RE, Langa KM, Melzer D. Income and the midlife peak in common mental disorder prevalence. Psychol Med 2011;41(7):1365–72.
  12. Dryden R, Williams B, McCowan C, Themessl-Huber M. What do we know about who does and does not attend general health checks? Findings from a narrative scoping review. BMC Public Health 2012;12(1):1–23.
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